Using Photobiomodulation to Ease Temporomandibular Pain

Photobiomodulation (PBM) has been used clinically in treating the temporomandibular (TMD) joint for more than 30 years. PBM has been increasingly used in other countries but is not as widely used in the US for TMD joint pain. PBM uses light energy to repair damaged areas for a patient.

PBM is like photosynthesis in plants but uses certain wavelengths of light in the red and infrared spectrum (the ideal range is 660-840 nm). PBM causes intracellular photochemical changes that lead to a cascade of downstream intracellular photochemical, extracellular, and physiological changes. The mitochondria within the cell wall are particularly receptive to this process. At the cellular level, visible red and near-infrared light energy is absorbed by mitochondria, which produce cellular energy called adenosine triphosphate (ATP).¹ PBM’s use in treating the existing TMD joint and/or pain and dysfunction in masticatory muscles impacts the biological process, especially inflammation, and is considered an adjunct treatment modality in TMD cases.

This article will focus on the use of PBM to aid in the dysfunction of the TMD joint. PBM will aid in decreasing inflammation in the joint, increasing endorphins associated with masseter muscle, and the stimulation of acupuncture points (an Eastern medicine). PBM can stimulate the acupuncture areas; this is called photoacupuncture (combination of PBM and acupuncture points). The World Association for Photobiomodulation Therapy defines photoacupuncture as “photonic stimulation of acupuncture points and areas to initiate therapeutic effects like that of needle acupuncture and related therapies together, with added benefits of PBM.” Photoacupuncture helps to repair the physical dysfunction, relieves pain, and aids in the comfort of the patient.²

When treating patients, the first procedure is to document the maximum opening without pain (Figure 1). You can use this device or your fingers to measure the opening from the maxillary incisors to the mandibular incisors (Figure 2). The patient should be able to open to 3 fingers’ width. The mean opening in a study done by Zawawi et al was around 48 mm.³

Next, use photography to document the area in the masseter that creates the most pain (Figure 3). By documenting this area, auxiliaries will be able to make quick reference to the site of the masseter that creates a trigger spot for pain during function just by touch. During the first session you will want to overstimulate the site to get pain relief (release the body’s endorphins). This site is normally treated with 12 to 15 J of energy as shown with a 1-minute duration using a 25-mm extraoral device (Ultradent Products’ Gemini 810 + 980 diode laser with PBM attachment; Figure 4). Cell physiologists have shown that use of 4 to 6 J of energy produces healing amounts of light energy, whereas using more than 12 J overstimulates the pain receptors.³

As discussed earlier, stimulation of photoacupuncture points also stimulates the area around the ear (Figures 5 and 6), but this is done with 4 to 6 J of energy to each site. These areas need to be treated at each visit with the same 4 to 6 J of energy.

The other stimulation sites are the lymphatic sites in the head and neck areas. TMD creates inflammation in the joint, so by treating the lymphatic system, you can reduce inflammation in the head and neck area.⁴ Treatment of the submandibular and the subclavicular lymphatic ducts with 4 to 6 J of energy at each site will need to be done during each visit (Figures 7-10). Using this regimen every 4 to 5 days between sessions brings the most optimal results, with the only change being to stimulate the trigger point in the masseter with 4 to 6 J of energy after the first session.

Figure 1

Using 3 fingers is considered an adequate way of measuring the opening from the maxillary incisors to the mandibular incisors.

Figure 2

A clinician works to find the trigger point in the masseter that causes the patient the most pain.

Figure 3

An extraoral device is used to treat the trigger point in the masseter.

Figure 4

Stimulation of photoacupuncture points also stimulates the area around the ear.

Figure 5

Photoacupuncture points are stimulated with 4 to 6 J of energy at each site.

Figure 6

Photoacupuncture points need to be treated with 4 to 6 J of energy at each visit.

Figure 7

A clinician stimulates a patient’s right submandibular lymph node.

Figure 8

Stimulation of the left submandibular lymph node will need to be done at each visit.

Figure 9

A clinician stimulates the right subclavicular lymph node.

Figure 10

A clinician stimulates the left subclavicular lymph node.

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The treatment is not a one-and-done procedure, as it must be done for 1 session after the patient states they have significant reduction of pain and mobility to allow normal opening of the mouth without pain (6-8 sessions). The patient may have several months of relief until stress creeps back into their life and they begin overfunctioning and stressing the TMD area.

Many insurance companies cover the expense of this treatment, which we charge at the first session and do not charge anything further to prevent patients from stopping treatments early due to concerns about cost. Insurance codes used are D7899 (unspecified TMD therapy, by report) and D9130 TMD (noninvasive physical therapy). Another dental code that can be used is D9110 (palliative emergency treatment of dental pain). Unfortunately, insurances rarely pay using this code. For medical coding, use 97032 (electric stimulation, manual, each 15 minutes) if you have the capability to submit by these means.

Following this treatment plan works well but requires patient adherence to the number of visits needed for success. Let patients know up front that you cannot guarantee success, but the resolution of limited opening and related discomfort should be possible—especially if the patient changes habits, such as refraining from chewing gum and eating chewy foods like submarine sandwiches or bagels that put stress on TMD joints.

Some may still consider this hocus-pocus dentistry, but it does work and there are numerous articles in PubMed showing PBM makes a significant difference.⁵ One great resource for learning more about PBM treatment is the Academy of Laser Dentistry. PBM does work and has many uses in dentistry and in medicine.

Clinical images courtesy of Dr Edward Kusek.

References

1. Azeemi STY, Rafiq HM, Ismail I, Kazmi SR, Azeemi A. The mechanistic basis of chromotherapy: current knowledge and future perspectives. Complement Ther Med. 2019;46:217-222. doi:10.1016/j.ctim.2019.08.025
2. Sun G. Photoacupuncture: combining Eastern and Western medicine for integrative healing. Academy of Laser Dentistry. November 2023. Accessed May 6, 2024. https://www.laserdentistry.org/index.php?option=com_dailyplanetblog&view=entry&year=2022&month=11&day=22&id=36:photoacupuncture-combining-eastern-and-western-medicine-for-integrative-healing
3. Zawawi KH, Al-Badawi EA, Lobo SL, Melis M, Mehta NR. An index for the measurement of normal maximum mouth opening. J Can Dent Assoc. 2003;69(11):737-741.
4. Madani A, Ahrari F, Fallahrastegar A, Daghestani N. A randomized clinical trial comparing the efficacy of low-level laser therapy (LLLT) and laser acupuncture therapy (LAT) in patients with temporomandibular disorders. Lasers Med Sci. 2020;35(1):181-192. doi:10.1007/s10103-019-02837-x
5. Xu GZ, Jia J, Jin L, Li JH, Wang ZY, Cao DY. Low-level laser therapy for temporomandibular disorders: a systematic review with meta-analysis. Pain Res Manag. 2018;2018:4230583. doi:10.1155/2018/4230583